View Medical Policies

For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.

Please refer member-specific questions to the Customer Care number on the back of the member card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.

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Showing 1– 20 of 301 Results
Title Last Updated Category
Acupuncture and Auricular Electrostimulation Open a PDF 8.01.20 2024-05-02 Alternative Medicine
Deep Brain Stimulation Open a PDF 7.01.23 2024-05-02 Nervous Systems (Neurology)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-04-30 Radiation Treatment
Immunizations Open a PDF 2.01.42 2024-04-29 Vaccines (Immunizations)
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2024-04-29 Miscellaneous
Second Medical and Surgical Opinions Open a PDF 10.01.10 2024-04-29 Miscellaneous
Optical Coherence Tomography for Ophthalmological Applications (OCT) Open a PDF 9.01.10 2024-04-29 Eyes (Ophthalmology)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2024-04-29 Nervous Systems (Neurology)
Lung and Lobar Lung Transplant Open a PDF 7.02.10 2024-04-29 Transplants
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2024-04-29 Nervous Systems (Neurology)
Magnetic Esophageal Ring/Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2024-04-29 Digestive System (Gastroenterology)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2024-04-29 Ear, Nose & Throat (Otorhinolaryngology)
Continuing Day Treatment Programs Open a PDF 3.01.20 2024-04-29 Behavioral Health (Psychiatry/Psychology)
Germline Genetic Testing for Hereditary Cancers Open a PDF 2.02.60 2024-04-29 Genetic Disease (Inherited Disease)
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2024-04-29 Lab Tests (pathology)
Bone Growth Stimulators Open a PDF 1.01.53 2024-04-29 Bone & Joints (Orthopedic)
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2024-04-29 Durable Medical Equipment & Supplies
Positron Emission Tomography (PET), Oncologic Applications Open a PDF 6.01.29 2024-04-19 Radiology (x-rays) & Imaging
CT (Computed Tomography) Perfusion Imaging of the Brain Open a PDF 6.01.37 2024-04-15 Radiology (x-rays) & Imaging
Magnetic Resonance Imaging‒Prostate/Multiparametric MRI Open a PDF 6.01.46 2024-04-15 Radiology (x-rays) & Imaging
Showing 1– 20 of 301 Results

 

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